Brickyard Healthcare - Elkhart Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were available and administered as ordered (Resident B) and failed to ensure a residents reviewed for medications was assessed for potential adverse side effects. (Resident 13) This deficient practice affected 2 of 7 residents reviewed for medications. (Resident B and 13) Findings include: 1.The closed record for resident B was reviewed on 8/8/2025 at 7:52 A.M. Diagnoses included: diabetes, kidney transplant, epilepsy, atrial fibrillation, gastro esophageal reflux disease and depression. The resident was re-admitted to the facility on [DATE] and was discharged on 6/24/2025. Resident B's May and June medications included the following: Apixaban 5 mg (milligram) 1 tablet twice a day; Glipizide 10 mg 1 tablet every day; Pantoprazole 40 mg 1 tablet twice a day and Pregabalin 50 mg 1 tablet once a day. A Nurse's Progress Note, dated 5/10/2025 at 9:07 P.M. indicated the Apixaban medication was unavailable and was not administered. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to implement their policy related to reporting an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes: During an interview on 1/22/25 at 12:45 P.M., Resident B indicated one night the previous week, Employee 3 entered her room to assist with changing her brief. Resident B indicated Employee 3 commented the odor was strong and sprayed her buttocks with room deodorizer and then pushed the spray can into her rectum. Resident B indicated on 1/20/25, at an unknown time, she was in the lobby of the facility and reported the incident to Employee 6. Resident B indicated on 1/22/24 during morning physical therapy, she reported the allegation to Employee 2. During an interview on 1/22/25 at 1:15 P.M., the Administrator indicated he was made aware of an allegation of abuse for the first time from Employee 2 on 1/22/25 at 12:30 P.M. The Administrator indicated he immediately suspended Employee 3, pending an investigation, reported the allegation to the State Agency, and initiated an investigation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure food was served at palatable temperatures in 1 of 1 kitchens observed (Main Kitchen). This deficient practice potentially affected 110 of 120 residents who consumed food from the main kitchen. Finding includes: During a meal observation with [NAME] 1 in the Main Kitchen, on 10/1/24 at 12:00 P.M., the food temperatures of hot foods on the steam table were a follows: pureed corn 105 F (Fahrenheit), cream corn 123 F, pureed beef 118 F, beef gravy 128 F, pepper steak 123 F, whole corn 141 and sweet potato 140 During observation of room trays on the 500 hall, conducted on 10/1/24 at 12:37 P.M., meals were transported to the unit, from the kitchen on metal covered, noninsulated carts. The last tray to be served, at 12:37 P.M., had the following food temperatures at the point of service: pepper steak 80 F, sweet potatoes 85 F and whole corn 85*F. During an interview on 10/1/24 at 12:05 P.M., [NAME] 1 indicated hot food temps should be held at or above 140 F while on the steam table. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was handled appropriately, foods were sealed appropriately, and failed to date foods when opened. This had the potential to affect 114 residents of 115 residents who received meals from the kitchen. Findings include: 1. An initial walk through of the kitchen with the Dietary Manager was completed on 7/29/2024 at 9:35 A.M. The following were observed: in the dry storage area was an opened/undated box of lasagna noodles not sealed, a gallon of vanilla with an opened date of 4/15/2023. In the walk-in cooler was an undated container of gravy and 3 health shakes with an expiration date of 7/23/2024, and an opened and undated box of Cream of Wheat cereal. 2. During a meal observation, on 7/29/2024 at 12:35 P.M., CNA 17 was observed to have her thumb extending over the plates' rim onto the food surface of the plate when serving 2 different residents. During an interview, on 7/29/2024 at 12:50 P.M., CNA 17 indicated her thumb should be underneath the plate. 3. During an observation, on 7/29/2024, CNA 18…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure resident funds were available on the same day of the request and for the desired amount for 4 of 4 residents reviewed for facility-managed personal funds. (Residents 18, 5, 31 and 8) Findings include: During an interview on 7/29/24 at 10:15 A.M., Resident 18 indicated he was able to obtain money from his facility account between the hours of 9 A.M. and 4 P.M. weekdays, and not at all on Saturday and Sunday. During an interview on 7/29/24 at 10:54 A.M., Resident 5 indicated he was only able to get five dollars from his facility account on the weekends. During an interview on 7/30/24 at 9:42 A.M., Resident 31 indicated she could only get money from her facility account until 4 P.M. weekdays, and not at all on Saturday and Sunday. During an interview on 7/30/24 at 1:15 P.M., Resident 8 indicated she was unable to get money from her facility account after 4 P.M. During an interview on 7/31/24 at 2:27 P.M., LPN 13 indicated the residents had a five dollar limit that they could take out of their facility accounts. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a surety bond sufficiently covered the total monies in the Resident Fund account. This had the potential to affect the 56 residents who had resident fund accounts managed by the facility. Finding includes: During an interview and record review of Resident Fund accounts, with the Business Office Manager (BOM) and the Executive Director, on 8/2/2024 at 8:25 A.M., the total amount in the Resident Fund accounts was $286,128.00. The BOM indicated the amount was higher than usual due to a closed account with funds from a home sale for which she was waiting on verification before sending the funds back to Medicaid. Review of the facility's Surety Bond insurance rider to cover Resident Fund monies, dated April 1, 2020, indicated the covered amount had been increased to $250,000. During an interview with the Executive Director (ED) on 8/5/2024 at 9:40 A.M. he indicated he did not know why the Corporation had not raised the Resident Fund Surety Bond amount higher. He confirmed the total amount noted on 8/2/2024 was unusually…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure baseline care plans were initiated for a resident receiving dialysis, a resident with falls and edema, and a resident with a wound, and failed to ensure baseline care plans were completed timely for a resident with an enteral feeding tube, for 4 of 27 residents reviewed for baseline care plans. (Residents 36, 107, 14 and 99) Findings include: 1. The record for Resident 36 was completed on 8/01/2024 at 8:48 A.M. Diagnoses included, but were not limited to, end stage renal disease, neurogenic bladder, viral hepatitis, and diabetes. An admission Minimum Data Set (MDS) assessment, dated 6/13/2024, indicated Resident 36 was receiving dialysis. A Baseline Care Plan form, dated 6/7/2024, indicated the resident required dialysis. The form lacked any goals, interventions, and any special needs to to address the resident's current needs to properly care for the resident. During an interview, on 8/2/2024 at 2:58 P.M., the Director of Nursing indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive person-centered plans of care were created related to behaviors, a urinary tract infection, constipation, impaired vision and edema for 5 of 23 residents reviewed for comprehensive care plans. (Residents 28, 10, 14, 66 & 215) Findings include: 1. The record for Resident 28 was reviewed on 7/31/2024, at 9:15 A.M. Diagnoses included but were not limited to: hemiplegia and hemiparesis, cerebral infarction, unspecified dementia, atrial fibrillation, cardiomegaly, hypertension, and anxiety disorder. Resident 28's current medications included Zyprexa (antipsychotic) 10 milligrams (mg) 1 tablet by mouth at bedtime for dementia with agitation. A Care Plan, dated 7/28/2024, indicated the resident had target behaviors of paranoia and agitation. Interventions included, but were not limited to, assess for pain, monitor for side effects of antipsychotics and report to the physician, monthly pharmacy review of the medication regimen, offer to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide accurate orders for resuscitative wishes for 2 of 3 resident reviewed for advanced directives. (Residents 94 & 36) Findings include: 1. A record review for Resident 94 was completed on 7/31/2024 at 11:19 A.M. Diagnoses included, but were not limited to: cerebral infarction, chronic obstructive pulmonary disease (COPD), congestive heart failure, atrial fibrillation, epilepsy, and diabetes mellitus type 2. An admission Minimum Data Set (MDS) assessment, dated 6/7/24, indicated Resident 94 had severe cognitive impairment. A Physician Orders for Scope of Treatment (POST) form, dated 6/1/2024, and signed by the nurse practitioner on 6/27/2024, indicated to not attempt resuscitation. A Physician's Order, dated 6/10/2024, indicated Resident 94 was a full code, indicating cardiopulmonary resuscitation to was to be completed. A Care Plan, dated 6/13/2024, indicated Resident 94 had an advanced directive of a full code. The goal, dated 6/13/2024, indicated that Resident 94's wishes would be honored. The interventions include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide resident-centered activities for 1 of 3 residents reviewed for activities. (Resident 93) Finding includes: During an observation on 7/29/2024 at 3:08 P.M., Resident 93 was lying in bed. There was no radio or television on in the room. On 7/30/3034 at 11:22 A.M., Resident 93 was observed in bed, with a loud hum of the oxygen concentrator and no radio or television playing. A record review was completed on 7/31/2024 at 8:57 A.M. Diagnoses included, but were not limited to: unspecified sequelae of cerebral infarction, anoxic brain, and tracheostomy. A Quarterly Minimum Data Set (MDS) assessment, dated 6/23/2024, indicated cognitive function could not be assessed due to unresponsiveness. An admission MDS, dated [DATE], indicated activity interview responses had no answers due to non-responsiveness. During observations on 7/31/2024 at 9:12 A.M. and 2:56 P.M., no music or television was observed to be on in the resident's room. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure edema was monitored for 1 of 1 residents reviewed for edema. (Resident 14) and failed to ensure antibiotic medication was administered timely for 1 of 2 residents reviewed for antibiotic use. (Resident 99) Findings include: 1. During an observation and interview on 7/29/2024 at 11:34 A.M., alert and oriented Resident 14 indicated he was admitted to the facility with edema to his bilateral below the knee amputation stumps. His prosthetic leg appliances were noted leaning against the wall in his room. He indicated his legs were too swollen to wear the prosthetic legs. The resident's lower thighs, knees and stump areas were noted to be swollen and looked similar in circumference to his upper thighs. A bandage was noted on the bottom of the left stump. The record for Resident 14 was reviewed on 7/31/2024 at 11:31 A.M. He was admitted to the facility on [DATE] with diagnoses including, but not limited to, major depressive disorder,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide a range of motion program to prevent further contractures for 1 of 2 residents reviewed for range of motion. (Resident 93) Finding includes: During an observation on 7/29/2024 at 3:11 P.M., Resident 93 was observed to have her hands in a fist-like position and her knees bent. On 7/31/2024 at 9:19 A.M., a straight legged, cushioned boot was observed sitting on a table at the end of the resident's bed. A record review was completed on 7/31/2024 at 8:57 A.M. Diagnoses included, but were not limited to, unspecified sequelae of cerebral infarction, anoxic brain, and tracheostomy. Past Physician's Orders included the following: - 3/28/2024-6/24/2024 Resting hand splint to right hand in the morning, and remove at night for skin integrity. - 3/27/2024-6/24/2024 Foot brace to left lower extremity drop foot. - 3/27/2024-6/24/2024 Passive range of motion to residents upper and lower extremities every shift and can be completed per Qualified Medication Assistant of Certified Nursing Assistant. A Physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide a peripherally inserted central catheter care for 1 of 5 residents reviewed for infection control (Resident 266) Finding includes: On 7/29/2024 at 9:32 A.M., Resident 266 was observed to have vancomycin and piperacillin hanging from an intravenous pole. He had a peripherally inserted central catheter (PICC) to his left antecubital space (the crook of the elbow), the transparent dressing, dated 7/24/2024, was folded in half with the insertion point site of the PICC line exposed. On 7/29/2024 at 2:37 P.M., the PICC line transparent dressing remained folded in half with the insertion point site of the PICC line exposed. During an observation, on 8/1/2024 at 9:45 A.M., the transparent dressing was observed to not be adhered along the lateral edges of the dressing. Resident 266 indicated he had received a shower the previous evening, and the dressing became wet. A record review was completed on 8/1/2024 at 10:14 A.M. Diagnoses included, but were not limited to, osteomyelitis, methicillin-susceptible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide adequate tracheostomy care for 1 of 1 resident reviewed for tracheostomy/ventilation. (Resident 93) Finding includes: During an observation on 7/29/2024 at 9:39 A.M., Resident 93's oxygen collar was observed to be to the left of her tracheostomy stoma site. On 7/29/2024 at 10:44 A.M., Resident 93's oxygen collar was observed to be at left of the tracheostomy stoma site. At 10:49 A.M., Qualified Medication Assistant (QMA) 19 was requested to obtain an oxygen saturation. The saturation level read 85-86 percent. QMA 19 indicated it was due to the way Resident 93 slept, and many interventions had been attempted. A rolled towel was observed on the right side of the neck. At 10:51 A.M., Resident 93's oxygen saturations were observed to be at 89 percent. Resident 93 was repositioned in bed, and at 10:53 A.M., her oxygen saturations were 92 percent. A record review was completed on 7/31/2024 at 8:57 A.M. Diagnoses included, but were not limited to, unspecified sequelae of cerebral infarction, anoxic brain,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to verify controlled substance counts for 1 of 1 medication cart observed. (SW Unit) Finding includes: During a medication storage observation of the SW Unit medication cart, on 8/2/24 at 9:43 A.M. with RN 11, the controlled medication log book had missing signatures for the count sheets on July 1, 5, 6, 11, 13, 14, 17, 18 and 27, 202.4 During an interview on 8/2/24 at 11:14 P.M., the Director of Nursing indicated all narcotic count sheets were to be signed by the oncoming and offgoing nurse/QMA for verification of residents' medications. A current policy was provided on 8/2/24 at 1:10 P.M. by the Director of Nursing. The policy, titled, Controlled Substance Administration and Accountability, indicated .for areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift 3.1-25(e)(2)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an appropriate diagnosis for a resident who received an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 28) Finding includes: The record for Resident 28 was reviewed on 7/31/2024 at 9:15 A.M. Diagnoses included, but were not limited to, hemiplegia and hemiparesis, cerebral infarction, unspecified dementia, atrial fibrillation, cardiomegaly, hypertension, and anxiety disorder. Current medications for Resident 28 included Zyprexa (Olanzapine - an antipsychotic) 10 mg (milligram) 1 tablet by mouth at bedtime for dementia with agitation. A Psychiatric Note, dated 7/24/2024 at 8:09 P.M., lacked an approved diagnosis and documented a plan by the psychiatric provider to continue Zyprexa despite being clinically contraindicated, as benefits outweighed risks. A professional resource, https://medlineplus.gov/druginfo/meds, indicated the following: Olanzapine is used to treat the symptoms of schizophrenia (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure staff change gloves and complete hand hygiene when providing perineal care for 1 of 1 resident reviewed for personal care. (Resident 47) Finding includes: During a random observation, on 7/29/2024 at 3:20 P.M., Resident 47 was observed lying on wet bed linens. Resident 47 indicated, they don't clean me up like they should. During a random observation, on 7/31/2024 at 1:23 P.M., Resident 47's call light was on. CNA 15 was observed answering the light. After the aide exited the residents' room, she indicated the room had a strong urine smell. CNA 15 indicated she smelled the urine and was not sure when he was checked or changed last. On 7/31/2024 at 1:38 P.M., CNA was observed to provide perineal care to Resident 46. CNA 16 applied gloves and obtained a wash basin and washcloth and a towel. He removed the brief, and with the same area of the washcloth wiped both sides of the residents groin, then washed the penis. He then rinsed the areas with another washcloth. With the same gloves still on, CNA 16 then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were kept in a locked cart when unattended, failed to ensure medication storage areas were free from loose medications; failed to date medications when opened during medication storage reviews for 4 of 4 medication carts observed and 2 of 3 medication rooms observed. (500, 300, 400 and 200 medication carts, 200 and 300 medication rooms) Findings include: 1. During a random observation, on 7/24/2023 at 5:35 A.M., the 500 Hall medication cart was observed to be unlocked with no staff in site of the cart. During an interview, on 7/24/2023 at 5:38 A.M., LPN 11 indicated the cart should have been locked. 2. During a medication storage observation, on 7/26/2023 at 9:35 A.M., on the 300 Hall medication cart with LPN 19 the following was observed: a loose pill was noted in a drawer. During an interview, on 7/26/2023 at 9:38 A.M., LPN 19 indicated there should be no loose pills in the medication cart. 3. During a medication room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the ceiling, oven, counters, and floor were clean and in good condition in the main kitchen; failed to ensure refrigerated foods were held at safe temperatures in the walk-in cooler; failed to dispose of expired foods; failed to ensure a refrigerator was clean; and failed to label and date foods brought in by residents, in 2 of 4 pantries (400 & 500 Halls) and the main kitchen. This deficient practice had the potential to affect 95 of 95 residents who received meals out of the kitchen. Findings include: 1. During an observation of the main kitchen, on 7/20/2023 at 9:45 A.M., with the certified dietary manager (CDM) the following was observed: A hole in the ceiling directly next to the air conditioning/heating vent that had an open bag of insulation hanging down and insulation was on the floor. Two buckets and four towels were under the vent and water was present on the floor. The outside of the oven had grease and food debris. The inside of the oven had a buildup of grease. The stainless-steel counters…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were accurately completed for 3 of 3 residents whose Advanced Directives were reviewed. (Resident 71, 72, & 4) Findings include: 1. A record review was completed on 7/21/2023 at 2:21 P.M. Resident 71's Physician Orders for Scope of Treatment (POST) form lacked the following documented information: the printed treating physicians name; the date; the office telephone number and the physician's licenses number. 2. A record review was completed on 7/24/2023 at 6:31 A.M. Resident 74's Physician Orders for Scope of Treatment (POST) form lacked the following documented information: the date; the office telephone number and the physician's licenses number. 3. A record review was completed on 7/21/2023 at 1:45 P.M. Resident 84's Physician Orders for Scope of Treatment (POST) form lacked the following documented information: the printed treating physicians name; the date; the office telephone number and the physician's licenses number. During an interview, on 7/27/2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to notify a plysician timely of missed doses of unavailable medication for 2 of 5 residents whose medications were reviewed. ( Resident 26 & B) Findings include: 1. A record review was completed on 7/25/2023 at 11:30 A.M. Resident 26's diagnoses included, but were not limited to: Multiple Sclerosis, epilepsy, depression, hypertension and diabetes. Current physician orders included: Vumerity delayed release capsule 231 mg (milligrams) 2 capsules 2 times a day related to MS (Multiple Sclerosis), and Ascorbic acid (vitamin C) 1000 mg daily. The June MAR (Medication Administration Record) indicated on June 1st the Vumerity order was documented as (3) hold/see nurses notes. The Nurses Note, dated 6/1/2023 at 9:17 P.M., indicated the Vumerity medication not given pending pharmacy delivery. The June MAR indicated on June 2nd and 3rd the Vumerity medication was documented as (7) other/see nurses notes. A Nurse's Note, dated 6/2/2023 at 10:53 A.M., indicated the Vumerity medication needs reordered. A Nurses' Note, dated 6/2/2023 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure pertinent transfer and resident clinical information was completed for 1 of 3 residents reviewed for transfers. (Resident 72) Finding includes: During an interview, on 7/20/2023 at 3:03 P.M., Resident 72 indicated he had gone to the hospital 2 weeks ago. A clinical record review was completed on 7/24/2023 at 2:12 P.M., Resident 72's diagnoses included, but were not limited to chronic kidney disease stage 3, obstructive and Reflux Uropathy, diabetes and depression. A Nurse's Note, dated 7/12/2023 at 8:45 P.M., indicated: QMA on staff contacted this writer to assess resident left Nephro tube, upon assessment this writer found left tube to be leaking urine from insertion site resident entire shirt soiled with urine. No urine noted in left leg bag and blood noted in tubing. On call NP (Nurse Practitioner) called - new orders to send resident to emergency room. A general note, dated 7/13/2023 at 2:32 A.M., indicated the resident returned from the hospital. Left nephrostomy tube was changed without incident and is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide transfer form information for 1 of 3 residents reviewed for hospitalization. (Resident 72) Finding include: During an interview, on 7/20/2023 at 3:03 P.M., Resident 72 indicated he had gone to the hospital 2 weeks ago. A clinical record review was completed on 7/24/2023 at 2:12 P.M., Resident 72's diagnoses included, but were not limited to chronic kidney disease stage 3, obstructive and Reflux Uropathy, diabetes and depression. A Nurse's Note, dated 7/12/2023 at 8:45 P.M., indicated: QMA on staff contacted this writer to assess resident left Nephro tube, upon assessment this writer found left tube to be leaking urine from insertion site resident entire shirt soiled with urine. No urine noted in left leg bag and blood noted in tubing. On call NP (Nurse Practitioner) called - new orders to send resident to emergency room. A general note, dated 7/13/2023 at 2:32 A.M., indicated the resident returned from the hospital. During an interview, on 7/26/2023 at 10:00 A.M., the Regional Director of Clinical Operations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide a care plan for the use of a continuous positive airway pressure (C-Pap) device for 1 of 28 residents reviewed for care plans. (Resident 15) Finding includes: During an observation on 7/20/2023 at 10:19 A.M., Resident 15's continuous positive airway pressure (C-Pap) mask was lying over the top of the machine on the bedside table. A record review was completed on 7/25/2023 at 10:36 A.M. Diagnoses included,but were not limited to: morbid obesity and renal dialysis. A Physician's Order, dated 6/22/2023, indicated a C-Pap at bedtime and as needed. A care plan was not located in the medical record for use of the C-Pap. During an interview on 7/26/2023 at 1:09 P.M., the MDS Coordinator indicated an order was placed for the C-Pap at admission on [DATE]. She indicated Resident 15 should have a care plan for the use of the C-Pap. On 7/27/2023 at 1:07 P.M., a policy titled, Comprehensive Care Plans was provided by the Regional Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure showers were provided timely for 1 of 3 residents reviewed for activity of daily living (ADL) care. (Resident 47) Finding includes: During an interview on 7/20/2023 at 11:15 A.M., Resident 47 indicated he was not receiving his showers routinely, and staff would state they were out of hot water or there was not enough staff to complete the shower. A record review was completed on 7/24/2023 at 11:53 A.M. Diagnoses included, but were not limited to: left below the knee amputation, muscle weakness, and chronic obstructive pulmonary disease. A 5-Day Minimum Data Set (MDS) Assessment, dated 6/17/2023, indicated Resident 47 was dependent with the assistance of one staff member for bathing. On a Significant Change MDS Assessment, dated 5/9/2023, Resident 15 indicated it was very important to him to chose between a tub bath, shower, bed bath or sponge bath. The Tasks section of the electronic medical record indicated Resident 47's showers were scheduled for Tuesdays and Fridays. A Care Plan, dated 3/23/2022,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide sanitation of the continuous positive airway pressure (C-Pap) equipment for 1 of 3 residents reviewed for supportive respiratory usage. (Resident 15) Finding includes: During an observation on 7/20/2023 at 10:19 A.M., Resident 15's continuous positive airway pressure (C-Pap) mask was lying over the top of the machine on the bedside table. A record review for Resident 15 was completed on 7/25/2023 at 10:36 A.M. Diagnoses included, but were not limited to: morbid obesity and renal dialysis. A Physician's Order, dated 6/22/2023, indicated a C-Pap at bedtime and as needed. During an interview on 7/26/2023 at 1:03 P.M., Resident 15 indicated the C-Pap tubing, mask, and canister had not been cleaned at the facility. On 7/26/2023 at 1:04 P.M., LPN 7 indicated there was not an order for washing the mask, tubing, or canister. The only order related to the C-Pap was to wear the C-Pap at night and as needed. On 7/27/2023 at 1:07 P.M., a policy titled, CPAP/BiPAP Cleaning was provided by the Regional Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure medications were available from the pharamacy for 2 of 4 residents reviewed for pain. (Resident 26 & B) Findings include: 1. A record review was completed on 7/25/2023 at 11:30 A.M. Resident 26's diagnoses included, but were not limited to: Multiple Sclerosis, epilepsy, depression, hypertension and diabetes. Current physician orders included: Vumerity delayed release capsule 231 mg (milligrams) 2 capsules 2 times a day related to MS (Multiple Sclerosis), and Ascorbic acid (vitamin C) 1000 mg daily. The June MAR (Medication Administration Record) indicated on June 1st the Vumerity order was documented as (3) hold/see nurses notes. The Nurses Note, dated 6/1/2023 at 9:17 P.M., indicated the Vumerity medication not given pending pharmacy delivery. The June MAR indicated on June 2nd and 3rd the Vumerity medication was documented as (7) other/see nurses notes. A Nurse's Note, dated 6/2/2023 at 10:53 A.M., indicated the Vumerity medication needs reordered. A Nurses' Note, dated 6/2/2023 at 7:37 P.M., indicated Vumerity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, clean, and comfortable environment was maintained, related to a broken towel rack, plastic wrapped around the cord of a power strip, stained ceiling tiles, broken heater, dead bugs in the light covers, and black mold on vents. (room [ROOM NUMBER], 217, 303, and 200, 400 and 500 Hall) Findings include: During an environmental tour, on 7/27/2023 at 2:30 P.M., with the Maintenance Director, Maintenance Assistant and Account Manager, the following was observed: room [ROOM NUMBER] had a broken towel rack. room [ROOM NUMBER] had a power strip plugged into the electric outlet but the cord to the power strip was still wrapped in plastic. The resident was using the power strip to power their television. There were ceiling tiles on the 200 hallway with large dark stains. room [ROOM NUMBER] had a broken baseboard heater. The 500 Hall had dead bugs that could be seen in five light covers. The 400 Hall had black mold that was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.